[HSF] ASD with LAD Disease
DukeB60 at aol.com
DukeB60 at aol.com
Tue Jan 1 11:07:51 EST 2008
Z,
I agree completely with your approach and experience. We have been
going down the same path. To do the same quality of valve repair or
revascularization but through a mini approach is, in fact, progress and patients
universally prefer it. I am intrigued by Mark's subxypoid approach for
revascularization to avoid the mini thoracotomy after robotic IMA harvest. Hope to visit
him soon.
Yesterday I did a 55 yo woman with supra systemic PA pressures due to
MS. She had irradiation for Hodgkin's Lymphoma many years ago and five years
ago had a three vessel CAB, AVR with St. Jude mechanical valve and mitral
repair with 26 mm Cosgrove ring at another institution. LV was preserved. She
now has a porcelain aorta very obvious on routine CXR and CT. I did her with
femoral cannulation and right chest approach with beating heart, cooling to
23 C. in anticipation of possible PHCA but never had to do so. I replaced the
valve which was stenotic due to misplaced band. Tried to re-repair but too
much scar and calcium. She is extubated and neurologically intact with PA
pressures already half what they were pre-op. I was able to get in a 27mm
valve.
Being familiar with the right chest approach, since almost all isolated
mitrals are done this way, was an enormous benefit.
Mini right chest valves are routine now and the next goal is port CAB
possibly with Cardica's C-Port. I have fired a bunch on open cases and they
give a good anastomosis for SVG and IMA with objective measurement and now need
to figure out how to load through port etc. I use the robot for a lot of
other things but not valves for a variety of reasons. Keep up the innovation
as it is important for the specialty's future.
Ed
Edward P. Raines, M.D., J.D.
BryanLGH Cardiothoracic Surgery
BryanLGH Medical Center East
1600 South 48th Str.
Lincoln, Nebraska 68506
Office: 402-481-8430
Cell: 402-730-9242
Fax: 402-481-8429
In a message dated 1/1/2008 9:15:38 A.M. Central Standard Time,
zzhoumd at pol.net writes:
Michael,
Happy new year!
I just saw him and he is up in the chair. One of the advantages of mini
thoracotomy is less bleeding. Total chest tube drainage is less than 200ml. Hct
is 37 (39 pre-op).
You brought up an important point. Mini invasive surgery is more for less
sick patients, although I did robotic MIDCAB in some sick patients. I have also
done heart port mitral valve replacement in a third time redo patient when
she had endocarditis and in septic shock. Again, it is not a silver bullet.
There should be different solutions for sicker patients like yours.
OPCAB was developed as a first step to compete with PCI, but it is not the
solution. We have to do better.
For me, This is the last day on call for a five day long weekend.
Z Zhou
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Michael Firstenberg" <msfirst at gmail.com>
Date: Tue, 1 Jan 2008 08:40:27
To:OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] ASD with LAD Disease
Z -
I am not picking on you - I am am glad that you see my points. Just has we
are operating on "less sick" patients such as yours (though it is suprising
that with that big of an ASD that he did not have more problems) we are also
operating on very sick patients and what concerns me is all of this
enthusiasm for high technology and cosmetic cardiac surgery in patients with
very little room for error.
I assume your patient is extubated and doing ok?
-m
On 1/1/08, zzhoumd at pol.net <zzhoumd at pol.net> wrote:
>
>
> Murtaza, thanks for your comments. I think the same principle can be used
> in mini valve cases if the patient has 1-2 vessel CAD.
>
> Z Zhou
>
>
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: murtaza chishti <cmurtaza at hotmail.com>
>
> Date: Tue, 1 Jan 2008 07:47:54
> To:<openheart-l at lists.hsforum.com>
> Subject: RE: [HSF] ASD with LAD Disease
>
>
>
>
>
> if the surgeon has the will, the patience, the skills and
> the infra-structure and can achieve the same surgical objective via a
> less traumatic and less disruptive approach, has the wisdom to select the
> appropriate candidate for a relatively unfamiliar operation and the
> foresight to anticipate trouble and the ability to forestall potential
> disasters, he/she should, without doubt , go ahead and do it; or else , how
> does the art and science of surgery advance?
>
> great work Dr Zhou
>
> murtaza
>
>
> > From: zzhoumd at pol.net
> > To: OpenHeart-L at lists.hsforum.com
> > Subject: Re: [HSF] ASD with LAD Disease
> > Date: Tue, 1 Jan 2008 00:36:26 +0800
>
> > CC:
> >
> > Michael,
> >
> > Thanks for all the comments. Mini invasive surgery dose not change the
> basics of open heart surgery. It is done with the same principle, but
> different approach with different instruments. I do not see the
> contra-indications for surgery have ever changed for sicker patients. But
I
> did see patients with less of disease become more acceptable for surgery.
> For example, single vessel disease such as we discussed earlier. Like Ani
> suggested, some cardiologists will manage single vessel disease medically.
> But I do have growing number of cases that cardiologists will send to me
for
> single graft to OM or RCA as patient is symptomatic. I have one patient has
> chronically occluded RCA for many years. After I grafted the distal RCA
with
> a mini incision and Robotic RIMA takedown, he told me that he felt 20 years
> younger and full of energy.
> >
> > Now come back to your question about bad lungs or obese patients. If
> just graft the LAD, the surgery can be down without bypass or sternotomy. I
> have done many of them and they do well. Patients with severe COPD, usually
> tolerate single lung ventilation well as I learned from my thoracic surgery
> experience. Obese patients can be challange, but I have done patients up to
> 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can
> be done as well. I think Hal can tell you more.
> >
> > Most patients can tolerate some degree of hypoxia. However, if I see
> sats below 90, I just let the anesthesiologist ventilate both lungs then
> find out the problem. LIMA takedown can be performed with both lung
> ventilation by increasing CO2 pressue in the left chest to creat enough
> space. I never hesitate to convert someone to regular sternotomy. For ASD
or
> mitral valve, just go on bypass with femoral cannulation then drop both
> lungs.
> >
> > Regarding heart-port, I just use the femoral cannulation part and their
> instruments. I never used their endo balloon. To avoid femoral cannulation
> complications, just ask anesthesia to check the descending aorta make sure
> no dissection. Most common complication is seroma, it can be avoided by
less
> of dissection and using Seldinger technique. One of my partner's patients
> did have compartment sydrome from DVT.
> >
> > There is no doubt that the surgery can be done much quicker with
> standard sternotomy. It is a little more work to do mini incisions.
> Therefore, the argument is, when finish and done, it looked really nice, if
> the patient did well, it may be worth it. If not, I will never do this
> again.
> >
> > Happy new year to everyone!
> >
> > Z Zhou
> >
> >
> > ----- Original Message -----
> > From: "Michael Firstenberg" <msfirst at gmail.com>
> > To: <OpenHeart-L at lists.hsforum.com>
> > Sent: Tuesday, January 01, 2008 10:04 AM
> > Subject: Re: [HSF] ASD with LAD Disease
> >
> >
> > > Z-
> > >
> > > Nice job, but this case clearly illustrates one of the problems with
> > > "modern medicine" and that being that everything can be fixed with a
> > > pill or a small "mini" incision.
> > > Would you (should you) have done the same operation had the Woods
> > > units been 10? (these are the ones we see) or if the patient was
> > > morbidly obese, 80 pack/year smoker? What about if his PAs were in
> > > the 30's from right heart failure. I know these are all "what ifs" -
> > > but we are talking about major life threatening/limiting problems
> > > where I think the magnitude and scope of the problems (or potential
> > > problems) that we deal with are underappreciated by all. The
> > > Interventionalist in the communities rarely see their patients with
> > > thrombosed LAD stents getting VAD or transplants (oh, wait it was
> > > just the patient's disease or their non-compliance). I assume you
> > > had to use single lung ventilation to get down the IMA - what would
> > > you have done had the increased PVR or hypoxemia put your patient
> > > into acute right heart failure? (and in the midst of trying
> > > medications to help, anesthesia - none for there attention to such
> > > details - give a giant air bolus which goes into the left heart and
> > > up to the brain?). May be a little hard to go back to work then. We
> > > all need to be realistic about the problems and promise we make, lest
> > > we make deals with the Devil. What in a full sternotomy, LIMA-LAD,
> > > standard bicaval cannulation, ASD closure - prevents him from going
> > > back to "a normal life" in 2 weeks. In fact, since the last couple
> > > of topics delt with how bad CPB is, I bet a "standard" approach would
> > > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies
> > > less painful than 1 sternotomy (you probably would not have had to
> > > open that widely). What are the statistics on complications of groin
> > > cannulation? 5 hours, hmmm - didnt we present a case recently of an
> > > compartment syndrome from femoral cannulation for an elective case.
> > > I thought Heart-Ports have fallen out of favor due to
> > > "problems"...... I could go on, but I admit I am a wuss and I am sure
> > > Hal will beat me up for this.
> > >
> > > I worked with a thoracic surgeon who "got away" with a lot due to his
> > > "innovative" (?creative) approaches - the problem, he also did not
> > > get away with it at times and had some huge problems from such
> > > misadventures.
> > >
> > > Nevertheless, great job - glad you helped the patient and made
> > > everyone happy. Just offering the other side
> > >
> > > -michael
> > >
> > >
> > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote:
> > >
> > >> In this day of age, just talking about survival for open heart
> > >> surgery or coronary artery disease is not enough. PCI has never
> > >> matched CABG in terms of survival or MACE (major adverse cardiac
> > >> event). PCI is gaining ground every year. We have to do our part as
> > >> well. Here is the case I did today.
> > >>
> > >> 65 year old active patient has 1 year history of increasing SOB.
> > >> TEE show large ASD not candidate for closure device. Cath show 70%
> > >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about
> > >> 60mmHg with resistance about 3 woods unit. (I can not remember
> > >> exact number, if someone interested, I can find it) Patient's
> > >> cardiologist ask me if I can do it with minimal invasive approach
> > >> as the patient wanted go back to normal life in short period time
> > >> without restrictions.
> > >>
> > >> Although it is general rule that I do not do CABG for mini-valve or
> > >> ASD, I decided to give a try. I used robot to take down LIMA, then
> > >> went to the right chest with 2.5 inch incision. Fem-fem cannulation
> > >> and clamp the aorta with modified heart-port technique. Fix the ASD
> > >> with a 3cm autologus pericardial patch. With aorta still clamped, I
> > >> made a second incision in left chest about 2 inch size and suture
> > >> the LIMA to LAD. It took me a little over 5 hours to do the
> > >> surgery, patient is doing well, already wake and will be extubated
> > >> tonight. Alternative, I could have done the whole thing with a
> > >> sternotomy in less than 3 hours.
> > >>
> > >> In summery, patient end up with two mini-thoracotomy incision, one
> > >> is 2.5 inches in the right chest, one is 2 inches in the left
> > >> chest. He also has a small incision for femoral cannulation. The
> > >> advantage, no sternotomy, no rib cutting, he can go back to normal
> > >> acrivities in 2 weeks with no restrictions. Disadvantage, longer
> > >> surgery time and a little more work for the surgeon.
> > >>
> > >> Any comments?
> > >>
> > >> Z Zhou
> > >>
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